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Abstract

A high degree of satisfaction is reported by patients of the homeopathic approach to health care [11]. Hahnemanns [10] postulations in Aphorism 2 of the Organon insist on a treatment that acts “in the shortest, most reliable and least detrimental of ways” (p.35). The routes by which remedies are administered can influence patient satisfaction with a regimen.

Central to this essay lies the question of the efficacy of the oral transmucosal remedy delivery over the oral swallow method. It is a common belief that, in homeopathic practice, an administered remedy needs to be dissolved on or under the tongue, such that absorption of the active properties via the oral mucosa is established. A survey has been conducted amongst practicing homeopaths evaluating their beliefs and experiences. The alternative routes of remedy delivery and the prevalence of the oral route have been identified via a second survey undertaken amongst suppliers of homeopathic remedies in 4 European countries.

The survey results have emphasized that the oral route of remedy administration has predominance over other routes of remedy delivery. Furthermore the outcome has clearly shown that the efficacy of a homeopathic remedy is believed not to be impaired if it is administered via the oral swallow route, without prior contact to the oral mucosa. The research of relevant literature has identified the homeopathic routes of administration as rated high in patient convenience and satisfaction.

In conclusion to the results of the surveys undertaken, it can be said that in future homeopathic practice the custom of supplying instructions of remedy administration to the patient can be facilitated immensely. Consequently, this may lead to increased patient compliance with the regimen. Further research is suggested.

Keywords: oral, swallow, transmucosal, routes of administration, convenience, compliance, satisfaction, homeopathy

Introduction

In the existing market economy that we have in the western world today, health care is increasingly being viewed as any other commodity that is demanded and supplied. With this development consumer satisfaction is augmented in value [18]. A patients´ satisfaction is influenced by aspects surrounding care and treatment, and may be decisive of acceptance and compliance with approaches that consequently may impact on the outcome of a therapeutic intervention [1].

The “empathic interaction with the health provider” [18] (p.377) is equally as important to the patient as are aspects such as the satisfaction with medication. The latter may influence the correct and continued intake of medicines and may ensure compliance with the prescribed regimen [1], [8], [25].

Besides the expected efficacy of medications, patients decisions are influenced by side-effects in relation to their medicine intake, the dosing regimen prescribed, the dietary restrictions associated and the routes of administration by which the medicinal substance is delivered into the patients system [8], [25]. The more convenient a drug delivery is, the better the patient feels in terms of compliance [5].

This paper aims to critically evaluate the routes of administration used in homeopathic prescribing. The deconstruction of the beliefs surrounding the oral-transmucosal route of remedy administration is sought to be refuted via the evaluation of available literature. The results of two surveys that have been undertaken are meant to deliver a re-constructive conclusion of the oral-swallow administration as a viable route for homeopathic remedy delivery.

 De-constructing the oral – mucosal route of administration

In conventional medicine the oral route of administration is the predominant method of drug delivery [24]. It is “the most convenient, inexpensive and safest route” [5] (p.197). The majority of drugs administered, whether in solid or liquid form, are being delivered into the body via the digestive system. What is taken in orally and swallowed is “absorbed into the blood system from the gastro-intestinal tract” [3](p.1398). For this purpose tablets, pills and capsules have to be produced in forms that withstand the exposure to the acidic environment of the stomach [2], the passage through the hepatic metabolism and rapid decomposition in the intestines [2], [3], [7], [24]. If this cannot be overcome, the exposure of the drug to the patients system in the digestive tract is diminished [3] and not enough active ingredient can be retained for the expected medicinal purposes of the drug to take action [5].

In my homeopathic practice, I have primarily made use of the `other´ oral route of drug delivery. I recommend to my patients, to allow dissolving on or under the tongue of the homeopathic tablet, pill, or granule such that the remedy may be absorbed through the mucosal lining of the mouth. The sub-lingual, gingival, buccal and soft-palatal mucosa are, according to research in allopathic medicine, the sites of the mouth where medicinal substances may best be absorbed into a patients’ system [24]. Hereby the above mentioned difficulties of degradation in the digestive tract are avoided, but exposure to drug substance is short and the drug action may be interfered by drink, food and other irritants that are absorbed through the mouth [24], [25]. Carlston [4] and Schütt [23] point this out for homeopathy and recommend that certain foods should be avoided directly before and after a remedy is allowed to dissolve in the mouth.

Although Hahnemann [10] suggests in the Organon (Aph.259 & 260) that obstacles to the cure, dietary and of regimen that could have a medicinal effect, are to be removed from the patient, no evidence could be found of Hahnemann being as precise as Carlston [4] and Schütt [23] above are. Hahnemann also does not suggest the inefficacy of a remedy if it is exposed to the acidic environment of the digestive tract. In fact, Hahnemann in Aphorism 284 describes the stomach as site of absorption, suggesting that he did not expect remedial action to be diminished if a remedy had been swallowed without prior contact to the oral mucosa.

From the Organon [10] it could not be extrapolated that Hahnemann explicitly insisted on the oral-transmucosal remedy delivery. Hahnemann [10] speaks in the Organon of “Gabe”, what is best translated as `administration´ [14]. In the Footnote to Aphorism 247 Hahnemann [10] employs the term “einnehmen” which refers to `ingestion of´ [15]. In Aphorism 272 he describes to the homeopath that a “granule placed dry on the tongue, is one of the smallest administrations for the less severe, only recently developed cases of disease” [10] (p.158). He goes on to point out that as such, only few nerves are touched by the medication. Further he describes that if the granule is dissolved in water and is prior to repeated ingestion succussed; a much stronger medication is created of which even the tiniest dose comes into instant contact with many nerves [10]. Yet, this also does not deliver indications for a definite necessity of transmucosal absorption.

This raises the question if the practice, of keeping the remedy in the oral cavity for transmucosal absorption is at all necessary. Many authors [4], [6], [13], [21], [23] suggest this as an explicit necessity for the remedy to be able to unfold its healing action.

Consequently, more questions have arisen. In what form are remedies most prevalently prescribed? What are the beliefs of practising homeopaths? Is it necessary to allow the remedy to dissolve in the mouth or is it also effective if swallowed? What other routes of administration are being used in practice?

Questions and answers – Survey 1

In a quest to answer those questions, two colleagues and I forwarded a questionnaire to fellow homeopaths on two homeopathic social networking sites, asking them to share their experiences and beliefs of the efficacy of oral-swallow versus oral-transmucosal remedy absorption and other routes of administration they used in their practice. The outcome was interesting.

Table 1

Table 2

As can be extrapolated from table 1 all homeopaths that replied to the questionnaire use the oral route of administration of remedies. 70% also used topical, 20% olfaction and 10% other forms of remedy delivery, namely playing with/holding of the closed vial. In table 2 is shown that 89% of homeopaths believe that if a remedy is swallowed, without prior dissolving in the mouth, it is still effective. 11% oppose this belief and state that swallowing is not effective.

Survey 2

A second questionnaire was formulated that was sent to suppliers of homeopathic remedies in the U.K., Germany, Austria and Switzerland. Here it was of interest to us to identify the greatest demand for and supply of different remedy types. Of 11 companies that were contacted, 10 replies were received in time for inclusion in this paper. The following table shows the companies contacted:

U.K.

Austria

Germany

Switzerland

Helios

Remedia

Weleda

Omida

Freemans

Spagyra

Alcea

Similisan

Ainsworth

Staufen

DHU (*)

(*) the reply from the DHU, came too late for inclusion in this paper.

Chart A: Suppliers contacted

In the U.K. the main remedy forms supplied are tablets and pillules, in Austria and Switzerland it is granules, whilst in Germany granules, liquid, and tablet are greatest in demand. Austria and Switzerland have producers that supply Collyria of homeopathic remedies. Only in Germany are remedies available as injections. Crèmes and Suppositories / Pessaries are in supply in all four countries. The greatest variety of homeopathic remedies forms is available via suppliers in the U.K.. It is interesting that in the U.K., Tablets and Pills are the predominantly purchased forms of remedy, while in continental Europe granules are highest in demand.

What becomes evident is that the oral administration has predominance in homeopathy. The highest demand is for remedy forms that are delivered via the oral route of administration.

There is a demand for homeopathic remedies in the form of injections in Germany, an invasive route, belonging to allopathic medicine that is low in patient compliance [1] and much in opposition to the gentle homeopathic approach postulated by Hahnemann [10]. In survey 1, of homeopaths in practice, this route could not be identified as one common to the field of homeopathy. It requires therefore to be pointed out that Staufen is a producer of homeopathic products and of spagyria, and Weleda a supplier of homeopathic and anthroposophic remedies. It could not be identified whether injections were of a greater quantity in use for spagyric and anthroposophic treatment or classic homeopathic use.

In their response `Staufen´ point out that the increasing demand of granules may be down to self-medication of the public with homeopathic remedies, while the demand for injections reflects a pure practitioner demand [20].

The replies also showed that there are other sites of transmucosal drug passage used in practice. These may be the nose, eyes, rectum, and vagina [3], [24]. The demand for remedies in the form of Collyria, pessaries and suppositories, shows that homeopaths also use these routes of administration.

Below is a table that illustrates the quantitative differences in the demand for certain remedy forms. As not all suppliers have shared numeric data, the graph contains only the data of those that have. I have only included 3 product items for each supplier.

                                       

Chart B: Approximate quantities supplied

What becomes visual in this chart is the great prevalence of oral solid remedy forms over oral liquid forms. Chart b also provides an idea of the quantities demanded of other remedy forms that are not visually shown in this graph. They are very low.


Reconstruction – The other routes of administration

The results extrapolated from the surveys, and the lack of evidence insisting on the oral-transmucosal remedy administration, have shown clearly that the efficacy of homeopathic remedies is believed not to be reduced if administered by swallowing.  At the same time the evidence for the requirement of precautions and restrictions ultimately before and after the intake of remedies is absent in the principal homeopathic literature. Hahnemanns [10] exclamations made in the Organon relate to the intake of substances with medicinal effect only (Aph.259 & 260), and he does not make any restrictions as to time, such as before and after remedy intake. This may remove, in future practice, the directions of remedy administration supplied by practitioners to their patients and narrows the general restrictions frequently given by the practitioner; a development Hahnemann [10] much criticized in followers of homeopathy (Aph.260). Thus convenience for the patient is augmented.

Alternative methods of administration are being used by practicing homeopaths, as can be seen in table 1. Taking into consideration the results visualized in chart B, the use of these is relatively small. Within the Aphorisms of the 6th Organon there is little mentioning of other routes by which remedies could be delivered. Only in Aphorism 284 does Hahnemann [10] describe sites of absorption other than tongue, mouth and stomach, mentions olfaction and inhalation and points out that the skin is also appropriate for remedy administration especially if concomitant to the oral intake of the remedy.

Of the alternative routes, topical administration finds greatest mentioning in the 6th Organon and is further described in Aphorism 285, and the footnote of Aphorism 282 in the case of Warts. There is supply of topical applications by 7 of the 10 suppliers of homeopathic remedies interrogated for our survey and table 1 shows that this route is one chosen in practice by 70% of homeopaths. According to Atkinson et al. [1] oral and topical administrations in conventional medicine are rated by patients as of highest satisfaction and convenience.

In Aphorism 272, as mentioned above, Hahnemann [10] describes the single granule dry on the tongue as the smallest dose, and in `The Chronic Diseases´ he also says this of “moderate smelling of an open vial” [16].

According to Little [17] alternative routes of administration may become necessary, where a remedy cannot be given orally, so for example if a patient is unconscious, or as McKay [19] describes, if patients are “in their final stages of life” (n.p.), when the open vial can simply be held under the sleeping patients nose to allow administration via inspiration. Also with children and infants this is an effective alternative form of remedy delivery [19]. Little [17] points out that in the 5th Organon (Aph.288) Hahnemann describes in detail how inspiration via mouth or nose can be used to deliver the remedy and further explains that it may even suffice for the sensitive patient to hold or touch the closed remedy vial. This is being practiced by 10% of homeopaths who replied to our questionnaire (Table 1).

An indirect delivery method Hahnemann [10] goes on to describes in Aph. 284. Here the remedy for the ill baby is to be given to the breast feeding mother. The child will consequently receive the remedy via the breast-milk [10].

Homeopathy is a person-centred approach that values the totality of the patient and respects the patients´ individuality [11]. As such the methods of remedy delivery offer a wide range of routes to be used to the patients convenience and best compliance. Kayne [13] points out that in conventional medicine the therapeutic efficiency is the prime determinant of the form in which a drug is delivered. In homeopathy the choice of form of remedy is one dependant on patient convenience solely [6], [13]. The same applies to the routes by which drugs are delivered [9].

Conclusion

In conclusion it can be said that improvement of methods of administration is not relevant to the practice of homeopathy. Hahnemann propagated different routes of remedy delivery ever since the creation of homeopathy [23]. The results of the above surveys have indicated that the oral route of delivery is by far the most extensively employed route of administration and that homeopaths in practice have a marked preference of using remedies in solid forms. The common belief that remedies need to be kept in the mouth and be allowed to dissolve has not been affirmed in practice as our survey has shown. Efficacy is maintained even if a remedy is swallowed.

The outcomes of the surveys and the preceding literature search have helped to identify the homeopathic method of remedy delivery as one of increased convenience and compliance to the patient. These routes, as postulated by Hahnemann [10], are non-invasive and adaptable to patient request and preference. By Hahnemanns own words in Aphorism 2, a homeopathic treatment should lead to “fast, gentle and durable recovery to health or elimination and annihilation of disease in all its complexity, in the shortest, most reliable and least detrimental of ways” [10] (p.35).

As much as convenience of the homeopathic methods of remedy delivery may receive high ratings of satisfaction and compliance by the patient, one problem may remain. There may be scepticism towards the efficacy of some of the alternative routes of administration of homeopathic remedies. Patients may doubt efficacy when the homeopathic practitioner insists that smelling a remedy may suffice for the expected healing action to take place [12]. Likewise it may be viewed rather sceptically if it is suggested to simply hold the closed vial [17]. Belief in the efficacy of these routes may be frail, despite the trust in homeopathy as an effective therapeutic approach.

It needs to be pointed out that further research to verify the efficacy of the oral swallow administration in homeopathy is relevant. The representativeness of survey 1above, reflecting the experience of practicing homeopaths, is very low as participation was only approximately 4.2 % of all homeopaths to whom the questionnaire was made available. For further research it can therefore be said that a social networking platform appears inadequate for the appraisal of a survey, even if, as in our case, the focus of the sites our questions were posted on was strictly homeopathic.

Acknowledgements

Many thanks to Rehana B. Issat for the assistance with the surveys used for this assignment and the presentation associated.

[Thanks to Hazel Partington and Jean Duckworth, University of Central Lancashire, for assistance with this assignment]

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